Overtesting and Overtreating Patients

Dr. Topol: I want to go back to when we were on a panel together. Obviously we're both interested in changing medicine -- all of us are, of course -- for the better. But we were on a panel and there was a urologist who was very adamant about still getting PSAs on all his patients. We tried to explain to him that we've stopped doing that now, but he wasn't going to take it.

Dr. Snyderman: No; in fact he was nasty.

Dr. Topol: Do you encounter that a lot?

Dr. Snyderman: I do. I think we, you and I, and traditional medicine have been part of the problem because as we created [new screenings to diagnose disease], we have sort of told patients to go out there and get [these screenings]. We haven't said to the American public, "You have to put some skin in the game, and that means you can't smoke, you really do have to watch what you eat, and get some basic exercise. You do those 3 things and you can ward off most diseases: heart disease, stroke, and a lot of cancers." Then there's the responsible patient asking, "How do I screen?" I tell people that there are 3 things they can do to get their baseline. Get a tape measure and check your waist; if it's over 35 inches for women or 40 inches for men, you have a problem. Get your blood pressure checked; you can get that done free at any drug store. And then, sometime in your 20s, pee in a cup and get a dipstick. At least then you have a pretty good idea [of what you're at risk for]. And, of course, know your family gene pool.

But the idea of taking the worried well and doing what we did in the 1950s for insurance policies, and applying it across this wide swath of people, makes no sense to me. A lot of times people will say, 'Well, a total-body CT scan only costs $750; I have the money for that." Well, you know what? You'll find something. I can guarantee you'll find something. Then the problem is [that after you find something] you don't want to pay for the rest of it; you want your insurance company to pick up the tab for the rest of it. And we go down this crazy path of what ifs. That little scar you find on your lung or that little blood vessel in your brain -- I'm not so sure you need to know about that to live a good, robust life.

So we waste money, we overuse things. In my field of ENT surgery, look at how many colds are treated with antibiotics. If you drop a piece of candy on the floor, would you pick it up and eat it? I do. I think bacteria are good for you. I wash my hands after I go to the bathroom and I wash my hands before I make dinner, but in the meantime I consider this sort of microworld around me good for my immune system. I don't get sick because I shake hands and I pick a piece of candy off the floor and eat it. I'll be fine. But I don't drink water from crazy sources in countries where I don't know where it comes from. It's using common sense, and somehow in medicine we have lived the extremes. We have people who want every test or we have people who refuse to go to the physician ever for fear of hearing something bad. Life is played between the 40-yard lines: dip in, dip out. Talk about death and dying, and how you want to slide out at home plate and don't consume all your healthcare dollars in the last year of life when that's a stupid way to use resources. I just think we have everything backwards.

Dr. Topol: But is it unique to the United States? Are the problems that we have, with so much waste and entrenchment -- is that a US thing?

Dr. Snyderman: It is a Western-world issue, but I think we are the worst offenders.

Nancy L. Snyderman, MD

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